Background
Shortness of breath or dyspnea is a common presenting complaint in the emergency department (ED), especially for patients over age 50, and is associated with high rates of death and morbidity. Older patients with dyspnea from conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and community acquired pneumonia (CAP) often require hospital admission. The issue of hospital admission decisions is an important question in modern health care. There is a significant shortage of hospital beds, EDs are overcrowded, and the decision to admit or discharge a patient from the ED is of considerable importance to the patient and to the health care system. There are no widely accepted guidelines to aid clinicians with the decision to admit or discharge these patients. Our research group has recognized expertise for developing clinical decision rules such as the Ottawa Ankle and the Canadian C-Spine Rules. Clinical decision rules are tools developed from original data to assist with bedside decisions. We also recently piloted a standardized assessment for ED patients with dyspnea, the Three-Minute Walk Test. We believe there is an urgent need to develop new decision rules to assist with admission decisions for patients with COPD, CHF, and CAP.

Objectives
The overall goal of this study will be to develop 3 separate and highly sensitive clinical decision rules to guide the admission decisions of physicians for older ED patients with acute dyspnea secondary to CHF, COPD, or CAP. In particular, these rules will be highly sensitive for predicting the potential for development of adverse events amongst patients with these 3 conditions. Specific objectives are to: 1. Prospectively evaluate patients for standardized clinical and laboratory assessments; 2. Evaluate patients for the 3-Minute Walk Test; 3. Evaluate patients for the development of adverse events within 14 days; 4. Determine the association between the clinical findings, laboratory findings, and the 3-Minute Walk Test with adverse events; 5. Use multivariate techniques to derive 3 highly sensitive clinical decision rules; 6. Assess the classification performance and potential impact of the derived decision rules; and 7. Determine if the adverse events should be considered "preventable".

Methods
Design: Prospective cohort study.
Setting: 4 EDs of large, tertiary care Canadian hospitals.
Subjects: Included will be all stable adults > 50 years, who are diagnosed with CHF, COPD, or CAP and are being considered for discharge by the attending ED physician. Excluded will be very ill patients ie. resting oxygen saturation < 90 % on room air or on baseline oxygen prescription, heart rate ≥ 110 bpm, systolic blood pressure < 90; inability to walk; chest pain or acute ECG changes. Waiver of informed consent will be sought from the Research Ethics Boards for this observational study.
Standardized Assessment: Patients will be assessed for standardized variables from the history and clinical examination as well as from routine laboratory values (hematology, chemistry, arterial blood gases [if ordered], BNP [for CHF], chest x-ray, and ECG.
Three-Minute Walk Test: This new ED assessment which has patients walk at their own pace on room air or home O2 level. Their respiratory rate, heart rate, and oxygen saturation will be recorded each minute for 4 min (3 min of walking followed by 1 min of rest).
Outcome Measures: The primary outcome measure will be "adverse event" defined as any of the following within 14 days: death, admission to a monitored unit, intubation, BiPAP after admission, myocardial infarction, or relapse for discharged patients (return to ED for shortness of breath).
Data Analysis: Predictor variables will be assessed for their univariate association with the primary outcome by chi-square or Student's t-test as appropriate. Those variables with strong univariate association and kappa values > 0.6 will then be assessed by multivariate recursive partitioning using KnowledgeSEEKER© software to develop a predictive model with very high sensitivity and the best possible specificity.
Sample Size: We anticipate enrolling the following numbers of patients over a 24-month recruitment period: Total - 3,000; CAP - 1,200; CHF - 1,200; COPD 600.

Importance
This study will develop important guidelines for the hospital admission of older patients with acute dyspnea. We expect these guidelines, once validated, will be widely used and will improve the efficiency of hospital admission practices and will also improve the safety of ED patient disposition decisions. Future research will validate and implement these clinical decision rules.

• Training Slides
• Research Proposal

OHRI members:

Cathy Clement, Manager
My-Linh Tran, Database Manager
Connor Sheehan, Research Assistant
Jennifer Brinkhurst, Research Assistant
Tami Clavet, RN, Coordinator

Other members:

Christine Belisle, Research Assistant - TOH - General Campus
Pam Sheehan, Research Assistant - TOH - General Campus
Sara Dorrington, Research Assistant - TOH - Civic Campus
Ginny Willis, Research Assistant - University of Alberta Hospital
Kathy Bowes, Research Assistant - Kingston General Hospital
Jane Reid, Research Assistant - Kingston General Hospital
Michelle Loftus, Research Assistant - Mount Sinai Hospital, Toronto
Antoinette Colacone, Research Assistant - Jewish General Hospital, Montreal
Chris Tselios, Research Assistant - Jewish General Hospital, Montreal
Yanka Mihaylova, Research Assistant - Jewish General Hospital, Montreal
Debbie Boyko, Research Assistant – Northeastern Community Health Centre, Edmonton